INJURY MANAGEMENT ASSIST Google

Submit a Referral to Injury Management Assist

Please expand the sections below to complete the referral form.

Injured Worker - ...
Full Name: Street:
Phone: Suburb:
Date of Birth: State:
Interpreter Lang: Postcode:
Occupation: Work Status:

Injury Details - ...
Type of Injury (s): Date of Injury:
Selected Duties: Claim Number:

Employer - ...
Employer: Street:
Phone: Suburb:
Fax: State:
E-mail: Postcode:
Supervisor: RTW Coordinator:

Agent - ...
Insurer: Street:
Contact: Suburb:
Phone: State:
Fax: Postcode:
Email: Liability Status:

Broker - ...
Broker: Street:
Contact: Suburb:
Phone: State:
Fax: Postcode:
Email:

Treating Doctor - ...
Full Name: Street:
Phone: Suburb:
Fax: State:
E-mail: Postcode:

Reason for Referral - ...
Case Management Initial Assessment
Workplace Assessment Functional Assessment
Vocational Assessment Transferable Skills Ax
Ergonomic Assessment S40 Assessment
Rehab Counselling Functional Education
Injury Management Consultant Ax Medical Clearance for Work
Job Seeking Assistance Job Ready Workshop
Other Treating Doctor Conference
Comments:

Referrer - ...
Name/Company: E-mail:

Approval Status for Injury Management Services
Insurer Approval: Preferred Office
 

Quick Links

Referrals
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Training
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Contact - View our locations
Sydney (02) 9821 3612
Brisbane (07) 3023 5036

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